HomeMy WebLinkAboutCLE201700018 Application 2017-02-08Application for Zoning Clearance_"�
CLE # �J I "I ` {1)
OFFICE U NLY
PLEASE REVIEW ALL 3 SHEETS Check # ` Date:
Receipt # � Staff:
PARCEL INFOR N -- O � 6�
Tax Map and Parce . ni
Existing Zoning 1
Parcel Owner
_
Parcel Address: Fj 7 P 9 `TriQi -E �'�(i , ' D c r uz fj--fState Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? (� /�21r iJKZ1
7
Address: I l)j &? fH1W—LE �" 1 f //� C / City State Zi c).)`}
Office Phone: L�
Cell # 874 9N— s7 i Fax #
P
E-mail ZoVkO Gj4Y+Gir�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name V New business
BusinessName/Type: ovkec) 5�1-4,'j2is.
Previous Business on this site a d k0
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide _T411 >F=SS /�1t17i32 �l r 1,{��
�Xt MjU
Clearance will be required. �rj �0 YE
*This Clearance will only be valid on the parcel or which it is approved. If you change, intensify or move the use to a new location, a new Zoning
I hereby certify that I own,oT have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to t .� my`_k�n�� ow edge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed JN+.-1L ze)VAr
-AP OVAL INFORMATION
[,f Approved as proposed [ ] Approved with conditions [ ] Denied
f ] w reventi ice and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official
Date
Date
Other Official I Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Is /(N 1
Is u LI, HI or PDIP zoning? If so, give applicant a Certified
Engi er's Report (CER) packet.
Y t
Wi ere be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies
Is parcel on private well or public water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or public sewer?
Reviewer to complete the following:
Square footage of Use:
Y/ N lyday- I t1 V it 1 )�J rmitted as:
Under Section:
Supplementary regulations section:
Parking formula: � f , 6 D 0 �► �.
Required spaces:
Y J `N
Ite s to e verified in the field: /
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign p mit.
Permit # l *Iar0 Pr\a& 1Inspector
Y / N Notes:
Will there b any new construction or renovations?
If so, o the proper Permit.
Permit #
Zoning to complete the following:
Date:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N /
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
EXHIBIT "A"
SITE PLAN
1st FLOOR PLAN - 5728 TO 5764 3-NOTCHED
SCALE 1116'=1'-O"
16
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office for that entity]
on
Date
/Mailing a copy of the application to
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
office for that entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Print Applicant Name
Date